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5. <br />6. <br />7. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />^ provide boat mooring and lake access for residential property. <br />____ provide swimming access, beach, or offshore dock. <br />____ provide a club or association gathering place for activities. <br />Dock is located on (check applicable item): <br />____ one member’s private property. <br />^ dacemestsr outlot owned in common. <br />____ property leased by the group/association. <br />____ property owned by the group/association. <br />List Dock location and ownership information: <br />Street address 3^03 K^l>/ f^V^NUk. MN 6^33/ <br />Legal property description c^utloT /^. CO'^i^________________ <br />PID# 30'/I«7-33 /:x €>oS^_ <br />t^STiH izVfht S»T>-b^ AV//tfrnr t I ■ i ■nmrir I IListed property owner(s) /^liNisms 1/ j jatLtO «/»/ <br />y. wrw^^ »5y4V<^ W. BeKTHfNaLi^ A-J C4>vT<Ac7 <br />Names of abutting lakeshore property owners: <br />(North/WesO_______/v^ot- ---------------------------------------------- <br />(Name + Address) <br />/>. //avT. iT. STteyr A7a/fSouth/EasO Qfjft^Laj <br />(Name + Address) <br />Names of other affected property owners: <br />• • •• * I <br />cmRurst.^tAHineg ar^f knFiLj ()NeNv£, rAf^STsr^/ <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used dock is insured by One of the following:- <br />• . * ‘ ‘____ property owner’s homeowner’s policy. <br />% <br />separate group/association owned policy. <br />List the following information: <br />'^Name of insured /CL'il'f Coy£ /tssoctA ’ftc^ ef- 6^0f/e> <br />Name of insurance carrier ciH^. iNN/yr'i c.s>hP^I£'S____;_____ <br />fiPPUcAfiotJ Name of insurance agency ^uujS__----------------------------- <br />Policy No. Rfftyer ______Effective date of coverage__________ <br />L-Amount of coverage: Public liability, per person, per occurrence $ f, coo, <br />Public liability, per occurrence $hoa*. ooo <br />Page 2 of 5